Important variables: results of the positive-deviance mail survey

Between December 1983 and May 1984, a mail survey on the topic of positive
deviance was sent to almost 700 nutrition and health professionals. The survey
questionnaire listed variables that were known or hypothesized to contribute to
positive deviance and asked the respondents to rate their importance. The
researchers requested survey responses from those health professionals with an
active interest in this topic. Responses were received from 68 persons in 36
countries in time to be included in the analysis (and from 25 more thereafter).
This response rate of about 13 per cent indicated to the research group that a
relatively large proportion of professionals in the nutrition field have an
active interest in this topic.

Table 8. Topics ranked by percentage of "important", items

Topic

Percentage

Child's resistance to infection

100

Mother's diet during pregnancy

75

Curative health care

71

Household resources

67

Mother-child interaction

60

Preventive health care, child's
physiological and dietary characteristics, family size and structure, family
attitudes, each

50

Psychological characteristics of mother

47

Fathers role

25

Behavioural characteristics of the child, characteristics
of other caretakers

0

Results

The results of the survey, including the regions and countries of the
respondents and descriptive statistics by rural and regional location, are
presented in Appendix I in tables A to F. Table G summarizes the open-ended
observations, suggestions, and comments written onto the questionnaires. The
names and addresses of the respondents are listed in Appendix 2 in order to
provide an informal reference group of professionals interested in the topic of
positive deviance.

It is important not to overanalyse these data, which are subjective in nature
and based overwhelmingly on personal observations by a selected group. One of
the primary purposes of presenting the results is to provide researchers with a
comprehensive list of variables and to enable them to refer to the survey
responses on an item-by-item basis when designing their own field-studies. Items
ranked as important by the survey respondents should clearly receive serious
consideration in both research and programme design. It is interesting to note
that 44 per cent of the questionnaire items received average rankings greater
than 3 on a scale ranging from 0 to 4.

By topic area, in descending order of importance, the percentage of items
under each topic with rank averages above 3 is shown in table 8.

Table 9 presents all items ranked as "very important" (score of 4)
by more than 50 per cent of respondents in the total sample or in either the
rural of urban subsamples. The writers believe these items should serve as a
useful "shortlist" of factors that should be taken into consideration
when studying positive deviance.

Both tables show that our experts gave highest importance to the role played
by infection in positive deviance.

Some rural/urban differences emerged from the results. In general, variables
reflecting modernization were ranked as being more important in the urban
setting. Greater contact with the outside world, fewer visits to traditional
healers, and less use of home remedies were ranked as significantly more
important for urban than for rural mothers. Characteristics of other caretakers
also ranked higher (quite possibly because urban employment tended to require
separation of mother and child). In the rural areas, presence of siblings old
enough to help the mother ranked higher. With respect to attitudes, mother's
satisfaction with her life was ranked more important in

Table 9. Survey of expert knowledge and opinion on positive deviance in
nutrition of young children (items agreed to be very important by 50 per cent or
more of respondents in overall, rural, or urban categories)

Percentage

Item

Overall

(N = 62)a

Rural

(N = 19)

Urban

(N= 14)

Mother-child
interactions

Early bonding between mother
and infant

63

44

69

Positive "affect" or
smiling happy mood between mother/child

52

53

39

Prompt
response to child's hunger cues

53

44

62

Frequent
psychosocial stimulation

53

53

39

Lack of prolonged separation
of child from mother

58

56

40

Behavioural characteristics of
the child

Rapid adaptation to new
stimuli

31

11

70

Psychosocial characteristics
of the mother

Satisfaction with her life in
general

52

39

58

Low levels of psychological
stress

51

46

46

Not overburdened by work

44

50

25

Ability to put child's needs before her own needs or
desires

53

50

50

Absence of psychiatric problems
(anxiety, depression, etc.)

44

40

62

Positive attitude towards
child (child of desired sex)

51

69

25

Maturity:
20 years old or more

36

50

39

Preventive health
care

Attention to hygiene and
sanitary conditions of child's environment

63

59

57

Greater use of modern preventive

health services (e.g.
pre-natal care, immunization)

61

53

57

Less
practice of dietary taboos

41

28

50

Curative health
care

Prompt visit to modern health
services

52

35

64

Continuing to seek help until
child recovered

47

25

50

Continuing to give
prescribed care and medication throughout the illness

49

29

54

Less restriction of diet during
illness

54

57

50

Father's role

Providing financial support for child

60

56

50

Family attitudes

Recognition of special nutritional needs of young child

59

43

50

Household resources

Presence of informal social network whose support the mother can
draw upon

44

53

40

Maternal nutritional status

Weight gain during pregnancy

45

55

55

Dietary intake during pregnancy

Calories

65

67

82

Protein

50

55

36

Iron

48

46

63

Dietary intake during
lactation

Calories

71

67

73

Protein

58

33

55

Child characteristics

Birth weight (large or average weight for date)

47

58

43

Normal gestational age (38-42 weeks)

50

67

43

Absence of complication/stress during pregnancy

42

55

23

Age supplementary food started

54

75

36

Age
breast-feeding stopped

47

50

64

Calories in supplementary
food

62

71

54

Greater than, average stress
tolerance

43

25

61

Child's resistance to
infections

Diarrhoeal

83

88

85

Respiratory

81

73

69

Parasitic

55

39

54

Measles

67

36

50

a. Not all responses could be included in this calculation since
some were respondents who wrote out their information in longhand rather than
answering the items. urban areas. Sex of the child was ranked less important,
and timing of the birth more important in the urban setting.

The numbers representing the different regions are too few to permit
statistical come parisons, although the regional values may be worth reviewing
for individuals interested in specific items. For example, the practice of
discrimination against female children was ranked as more important in Middle
South Asia (Bangladesh, India, Nepal, Sri Lanka, and Turkey) than in other
regions.

Discussion

In summary, the survey results underscore the importance of
nutrition-infection interactions for the study of positive deviance. These high
ratings given to health may in part reflect the fact that many of the
respondents were clinicians who encountered malnutrition in sick children
attending health facilities. The results confirm that many nutrition and health
professionals acknowledge the importance of psychosocial factors contributing to
child growth and particularly to the ability to thrive under conditions of
adversity. They also illustrate the fact that conditions contributing to
positive deviance differ significantly from one setting to another.

An interesting example of this difference is that sex of the child was ranked
more important in the rural areas, while timing of the birth was more important
in the urban areas. In many rural areas, particularly outside of Africa, land is
passed down from father to son and the multigenerational patrilocal family is
the production unit. Under these circumstances, a primary parent-son emotional
bond may be required to ensure intergenerational commitment to the economic
unit. The need for such preferential bonding would diminish with urbanization.
However, timing of births increases in importance as couples begin to limit
their fertility and mothers enter paid
employment.